Undersea & Hyperbaric Medical Society

HYPERBARIC OXYGEN TREATMENTS FOR COMPLICATIONS OF RADIATION THERAPY

Cancer treatment has improved significantly over the past decade. Although cure of the cancer is still the highest priority of treatment, cancer specialists have come to recognize the ever-increasing importance of quality of life to the cancer survivor. One-half of the estimated 1.2 million new cases of invasive cancer will receive radiation therapy as a part of their cancer treatment. Side effects of this therapy can be very toxic, especially when combined with chemotherapy. Some people are more sensitive to radiation damage than others, and there are no reliable tests available as yet to identify those patients who will experience the worst side effects. Radiation doses must be adequate to control the cancer; otherwise, there is no purpose in treating the patient. Most radiation cancer specialists or oncologists design their treatment protocols to give the best dose to control the tumor and still have no more than 5% of patients develop severe reactions to treatment.

Radiation side effects are generally divided into two categories. First, there are those that happen during or just after the treatment, called acute reactions. Second, there are those that happen months or even years after the treatment, called chronic complications.

The acute side effects almost always resolve with time and are treated in such a way as to address the patient’s symptoms. For example, when a patient has a cancer of the mouth or throat, it becomes very difficult for the patient to eat during and just after treatment because the lining of the mouth and throat becomes raw and painful. The cells which make up the linings of the gastrointestinal tract are sensitive to radiation. Both cancer cells and the cells that line the gastrointestinal tract have a high rate of growth, and this rapid growth rate makes them more sensitive to radiation damage. Fortunately, the normal tissue cells have excellent repair abilities and within a few weeks after the completion of radiation, this damage is repaired. In the meantime, the patient is supported with pain medicine and supplemental nutrition.

Unfortunately, chronic complications often may not get better with time and are likely to get worse. Almost all chronic radiation complications result from scarring and narrowing of the blood vessels within the area which has received the treatment. If this process progresses to the point that the normal tissues are no longer receiving adequate blood supply, death or necrosis of these tissues can occur. In the past, a severe level of necrosis would require surgical removal of the damaged tissue. This would be a devastating blow for a patient whose cancer has been cured. For example, though it occurs rarely, a patient who has had cancer of the voice box cured might require the removal of the voice box due to radiation damage. Chronic radiation damage is called "osteoradionecrosis" when the bone is damaged and "soft tissue radionecrosis" if it is muscle, skin or internal organs which have been damaged by the radiation.

Since the 1970’s, surgeons of the head and neck region have come to recognize the value of hyperbaric oxygen treatments in treating damage of the jaw bone due to radiation. Hyperbaric oxygen has had some of its most dramatic successes in treating or preventing damage to the jaw bone as a result of radiation treatments. It has now also been applied to damage of the brain, damage of muscle and other soft tissues of the face and throat, damage to the chest wall, abdomen and pelvis as a result of radiation treatment. Papers in medical journals also report success in treating damage to the bladder and intestines due to radiation. The high dose oxygen provided in the hyperbaric chamber is carried in the patient’s circulation to the site of injury to be available for repair of the damage done by the narrowing and scarring of the blood vessels. Each treatment typically takes one to two hours, and usually 30-40 daily treatments are needed for healing radiation damage.

Most insurance companies, including Medicare, will provide coverage to pay for hyperbaric treatments for chronic radiation injuries.

References

1. Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: A randomized prospective clinical trial of hyperbaric oxygen versus penicillin. J Am Dent Assoc 1985;11:49-54.
2. Hart GB, Mainous EG. The treatment of radiation necrosis with hyperbaric oxygen. Cancer 1976;37:2580-2585.
3. Feldmeier JJ, Heimbach RD, Davolt DA, Brakora MJ. Hyperbaric oxygen as an adjunctive treatment for severe laryngeal necrosis: A report of nine consecutive cases. Undersea Hyper Med 1993;20:329-335.
4. Marx RE. Radiation injury to tissue. In: Kindwall EP, ed. Hyperbaric Medicine Practice. Flagstaff, Best Publishing, 1995, pp 464-503.
5. Feldmeier JJ, Newman R, Davolt DA, Heimbach RD, Newman NK, Hernandez LC. Prophylactic hyperbaric oxygen for patients undergoing salvage for recurrent head and neck cancers following full course irradiation (abstract). Undersea Hyper Med 1998;25(Suppl):10.
6. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: A retrospective review of twenty-three cases. Undersea Hyper Med 1995;22(4):383-393.
7. Bevers RF, Bakker DJ, Kurth KH. Hyperbaric oxygen treatment for haemorrhagic radiation cystitis. Lancet 1995;346:803-805.
8. Woo TCS, Joseph D, Oxer H. Hyperbaric oxygen treatment for radiation proctitis. Int J Radiat Oncol Biol Phys 1997;38(3):619-622.
9. Warren DC, Feehan P, Slade JB, Cianci PE. Chronic radiation proctitis treated with hyperbaric oxygen. Undersea Hyper Med 1997;24(3):181-184.
10. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis. Undersea Hyper Med 1997;23(4):205-213.
11. Feldmeier JJ, Heimbach RD, Davolt DA, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen as an adjunct in the treatment of delayed radiation injuries of the extremities (abstract). Undersea Hyper Med 1998;25(Suppl);9.
12. Fontanesi J, Golden EB, Cianci PC, Heideman RL. Treatment of radiation-induced optic neuropathy in the pediatric population. Journal of Hyperbaric Medicine 1991;6(4):245-248.
13. Chuba PJ, Aronin P, Bhambhani K, Eichenhorn M, Zamarano L, Cianci P, Muhlbauer M, Porter AT, Fontanesi J. Hyperbaric oxygen therapy for radiation-induced brain injury in children. Cancer 1997;80:2005-2012.
14. Pomeroy BD, Keim LW, Taylor RJ. Preoperative hyperbaric oxygen therapy for radiation induced injuries. J Urol 1998;159:1630-1632.

Other references on Delayed Radiation Injury (Soft Tissue and Bony Necrosis):

SOFT TISSUE RADIONECROSIS

Note

The following papers represent a broad range of anatomic sites that commonly suffer tissue breakdown and loss as a consequence of radiation tissue injury. The pathophysiology associated with such injury is found to be largely identical to that which complicates bony tissue (osteoradionecrosis).

• Kindwall EP: Hyperbaric oxygen’s effect on radiation necrosis. Clinics in Plastic Surgery 1993;20(3):473-483.
  A comprehensive review, directed at the Plastic Surgery specialty.
• Anon.: Hyperbaric oxygen therapy for treatment of soft tissue radionecrosis and osteoradionecrosis. Health Technology Assessment Reports 1982; DHHS Publication No. (PHS) 84.3371.
  A United States Department of Health and Human Services Public Health Service "Health Technology Assessment Report" on the Treatment of Soft Tissue Radionecrosis …" Even as early as 1982 this report concluded that "there is little controversy in the medical community regarding the safety and effectiveness of HBO as an adjunctive therapy in the treatment of soft tissue radionecrosis…" Of course, in 1999 we have a greater appreciation of the precise pathophysiology of this disorder. So, too, the therapeutic effects of HBO therapy. Equally important is the evolution to a protocol-driven approach, in common practice today.
• Neovius EB, Lind MG, Lind FG: Hyperbaric oxygen therapy for wound complications after surgery in the irradiated head and neck: a review of the literature and a report of 15 consecutive patients. Head & Neck 1997;19:315-322.
  A literature review, from a hyperbaric perspective, involving head and neck radionecrosis. The authors then report their own clinical experiences, and conclude that HBO therapy has "a clinically significant effect on initiation and acceleration of healing processes …"
• "Feldmeier JJ, Heimbach RD, Davolt DA, et al.: Hyperbaric oxygen as an adjunctive treatment for severe laryngeal necrosis: a report of nine consecutive cases. Undersea & Hyperbaric Med 1993;20(4):329-335.
  The authors summarize their experience with laryngeal radionecrosis in nine patients. Notably, none of the nine patients required laryngectomy.
• Samuels L, Granick MS, Ramasastry S, et al: Reconstruction of radiation-induced chest wall lesions. Ann Plast Surg 1993;31(5):399-405.
  This paper is included in order to sensitize the reviewer to the enormous complications associated with repair of soft tissue radionecrosis without the benefit of perioperative HBO therapy. Modern reconstructive techniques were employed, and had to be repeated in several cases. The underlying problem of radiation-induced endarteritis dogged these procedures. Repeat and costly surgeries were necessary, essentially debriding the entire "radiation portal" of soft tissue in some instances. Two patients were left with non-healing wounds, another six (29%) suffered flap compromise (expensive failures!).
• Feldmeier JJ, Heimbach RD, Davolt DA, et al: Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: a retrospective review of twenty-three cases. Undersea & Hyper Med 1995;22(4):383-393.
  In contrast to the above article, improved outcomes resulting from the repair of chest wall defects are reported, when HBO therapy is incorporated into the treatment plan.
• Bevers RFM, Bakker DJ, Kurth KH: Hyperbaric oxygen treatment for haemorrhagic radiation cystitis. The Lancet 1995;346:803-805.
  A relatively large series of patients suffering radiation-induced cystitis, and treated hyperbarically. The paper notes the ineffectiveness of non-hyperbaric medical and surgical strategies. The impressive outcomes (37 of 40 patients healed) contrast sharply with previously reported case series, when patients were not afforded HBO therapy.
• Rijkmans, BG, Bakker DJ, Dabhoiwala NF, et al: Successful treatment of radiation cystitis with hyperbaric oxygen. Eur Urol 1989;16:354-356.
  Another clinical series in which HBO therapy was found effective. Interestingly, and as an aside, the use of HBO hastened the diagnosis of recurrent bladder tumor. Biopsy of radionecrotic bladder is largely hit or miss. Following a course of HBO therapy, the bladder wall normalizes in all areas except those involving tumor, making subsequent biopsies of suspected lesions more precise. This has critically important implications, of course. Those so identified will stand to benefit from earlier anti-cancer care.
• Lee HC, Liu CS, Chiao C, et al: Hyperbaric oxygen therapy in hemorrhagic radiation cystitis: a report of 20 cases. Undersea Hyperbaric Med 1994;21(3):321-327.
  Excellent to good (halted to markedly decreased hemorrhagic cystitis) outcomes in 90% of patients whose previous medical and surgical care had failed to resolve this radiation-induced complication.
• Williams JA, Clarke D, Dennis WA, et al: The treatment of pelvic soft tissue radiation necrosis with hyperbaric oxygen. Am J Obstet Gynecol 1992; 167(2): 412-416.
  Gynecologic soft tissue radionecrosis successfully treated with HBO therapy. All patients had failed three months of other medical and surgical therapies.
• Feldmeier JJ, Heimbach RD, Davolt DA, et al: Hyperbaric oxygen an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis. Undersea Hyperbaric Med 1996;23(4):205-213.
  A more recent publication again addressing pelvic and abdominal soft tissue radionecrosis. Providing that an "appropriate" course of HBO therapy was employed, healing of these complex complications of therapeutic radiotherapy occurred in 81% of 41 patients.
• Fine BA, Hempling RE, Piver MS, et al: Severe radiation morbidity in carcinoma of the cervix: impact of pretherapy surgical staging and previous surgery. Int. J. Radiation Oncology Biol. Phys. 1995;31(4):717-723.
  The reader is referred to this publication for the express purpose of appreciating the "severe radiation morbidity …" associated with carcinoma of the cervix. This involved 66 of 189 patients (34.9%). As with the two previous papers this work identifies the failure of medical and surgical plans that do not involve peri-operative HBO therapy.
• Reedy MB, Capen CV, Baker DP, et al: Hyperbaric oxygen therapy following radical vulvectomy: an adjunctive therapy to improve wound healing. Gynecologic Oncology 1994;53:13-16.
  HBO therapy, employed in a prospective observational manner, resulted in a reduction in wound breakdown and a shorter hospital stay.